Considering the role of opioids

Poorly controlled chronic pain not only leads to a decreased quality of life, but also depression, anxiety, insomnia, substance abuse, mood disorders, worsening of existing chronic diseases, and an increased risk of suicidal ideation associated with both chronic pain and opioid use.⁵

A retrospective study of people living with chronic pain concluded that those prescribed a morphine daily dose equivalent to or greater than 100mg had a higher suicide risk.⁶ The study also concluded that this risk didn’t vary much between levels of opioid dosage. 

NICE concluded that there was no evidence for the efficacy of opioids when used for chronic primary pain, with an increased risk of dependence associated with opioid use for longer than six months. 

Shared decision making

NICE recommends that when carrying out a review of a person’s pharmacological treatment of chronic primary pain, you should ensure that you are working with the person to reach a shared decision. This may mean that you formulate a plan to optimise these medicines, taking into consideration person- specific factors such as their health beliefs about the place of these medicines, and the initial impact that deprescribing would have on their day-to-day life.

After weighing up the benefits of deprescribing versus continuing these medicines as safely as possible, the pros and cons of both should be discussed (including explaining the lack of evidence for these medicines when used for chronic primary pain) to help the person living with pain reach a shared decision about the most appropriate course of action for them. If there is limited benefit or significant harm in taking these medicines, encourage and support deprescribing. However, if deprescribing proves to be a less appropriate option at that time, and the person reports benefits at a safe dose with few adverse effects, then a shared plan for safely continuing these medicines should be made.² 

Chronic primary pain, is defined as pain that persists for longer than three months and is associated with significant emotional distress or functional disability and that cannot be explained by another chronic condition.⁷ 

The Faculty of Pharmaceutical Medicine (FPM) states that despite the lack of evidence for the safety or efficacy of opioids for chronic primary pain, for a small subset of patients, opioids can be successfully used as part of a broader holistic plan featuring non-pharmacological treatments and self-management strategies.